7/11/17. The Surgeon s Operative Report: Tools and Tips to Enhance Abstraction. Stopwoundinfection.com. Impact to Healthcare

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1 1. Scott, R. Douglas. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. March Anderson DJ, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol. 2008; 29: S51-S61 for individual references. 3. Klevens RM, et al. Estimating Healthcare-Associated Infections and Deaths in U.S. Hospitals, Public Health Rep. 2007; 122: Anderson DJ, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol. 2008; 29: S51-S61 for individual references. 5. Kirkland K., MD., et al. The Impact of Surgical-Site Infections in the 1990s: Attributable Mortality, Excess Length of Hospitalization, and Extra Costs. Infect Control Hosp Epidemiol. 1999; 20: Harris R. Analysis of Surgical Site Infection Rates and Cost Benefits Associated with Plain Gauze Dressings Compared to Gauze Dressings Impregnated with Polyhexamethylene Biguinanide (PHMB). Am J Infect Control Jun; 36(5): E31-E32. The Surgeon s Operative Report: Tools and Tips to Enhance Abstraction Robbie Fennewald Applied Medical Sr. Director of Clinical Implementation Stopwoundinfection.com Impact to Healthcare days in hospital 8,000+ deaths ,000+ patients 3 +$3-10 billion to cost of healthcare 1 Surgical Site Infection(SSI) United States Impact % 5x more likely to be in ICU 5 higher risk of death 4 more likely to be readmitted x $27,631 direct cost to patient 6 1

2 Clinical Information Our data demonstrate that a statistically significant reduction in the incidence of wound infection was achieved with the use of a wound-protection device. This device provides a simple intervention that may eventually have a large impact on the incidence of surgical wound infection and therefore annual health care expenditures. In this study the use of barrier wound protection in elective open colorectal resectional surgery resulted in a clinically significant reduction in incisional surgical site infections There was a significant reduction in the incidence of incisional surgical site infections when the wound protector was used: 3 of 64 (4.7%) vs. 15 of 66 (22.7%). SHEA Compendium (Society for Healthcare Epidemiology of America) üappropriate Hair Removal üantibiotic Prophylaxis üpatient Warming üskin Preparation üwound Protection/Retraction Society for Healthcare Epidemiology of America (SHEA) Infectious Diseases Society of America (IDSA) Association for Professionals in Infection Control and Epidemiology (APIC) American Hospital Association (AHA) The Joint Commission Self retained wound retractors/protectors There are 3 Categories of disposable wound retractors/protectors Atraumatic Self retaining wound retractors Applied Medical Alexis Mobius Surgical Retractor Wound protectors Traumatic wound retractors Medtronic Surgi Sleeve Wound Drapes ( No retraction) Lone star Retractor 2

3 Colorectal resection and anastomosis Next, we made a small Pfannenstiel incision. Alexis wound protector was placed. The specimen was extracted through the Pfannenstiel incision. We selected a point proximal to the rectosigmoid junction for transection We placed 2 Allen bowel clamps on the sigmoid colon. I used a 10 blade to cut in between. The specimen was then removed from the field and sent to pathology. We used 2-0 Prolene to create a pursestring to sew in the anvil of the 33 EEA stapler. We then cleaned off additional adipose tissue that was around our planned anastomotic site. We then dropped the anvil into the abdominal cavity, reestablished pneumoperitoneum and completed our anastomosis in an end-to-end fashion using the EEA stapler size 33. We then irrigated copiously until clear fluid returned and excellent hemostasis. Alexis placed to exteriorize the colon. A small infraumbilical incision was made a proximally 6 cm in length. The peritoneum was identified and opened sharply. A small wound protector was then placed and the specimen was removed without difficulty. The proximal end of the bowel was marked with a suture ligature and the specimen was delivered from the field identified as sigmoid colon, stitch marks proximal. We identified the descending sigmoid colon and packed off the area around the wound protector. The end staple line was removed and the anvil of the EEA stapler was placed in the distal sigmoid colon and secured there with a 2-0 Prolene pursestring suture. Anastomosis The supraumbilical port was enlarged and the freed right colon and terminal ileum were mobilized through the wound with wound protector in place. The proximal distal colon and the small bowel were approximated along the tenia. A silk suture placed and a small enterotomy made in both. The linear stapler was then placed with a 75 ml load and it was fired. The open end of the bowel and specimen was transected using the TA 75. The specimen was removed from the operative field. The abdominal wall protector was closed and insufflation was reestablished and exploration and irrigation revealed good hemostasis present. No evidence of any significant bleeding. The trocars were removed. The abdominal wall protector was removed. Colon exteriorization during Lap procedure Does this procedure become laparoscopic converted to open based on the wording... "At this time, a 4 cm right lower quadrant incision was made. The abdomen was then entered and a wound protector was then placed. The terminal ileum and ascending colon were then extracted through this." An Alexis wound protector was then placed in the minilaparotomy incision and dissection of the hepatic flexure continued successfully mobilizing the colon into our surgical field. 3

4 Specimen removal through Alexis A 5 cm standard Pfannenstiel incision was made, carried through the subcutaneous and fascia. Peritoneum was entered. Alexis wound protector was placed and the specimen was retrieved through this wound. Contained Extraction devices What is the difference between a wound retractor/protector vs. an extraction device? Gel Products Applied Medical make 3 categories of Gel Products. GelPort GelPOINT and GelPOINT mini GelPOINT Path 4

5 Gelport system Gelport Surgery Procedure begun by making a 10 cm Pfannenstiel incision. A wound protractor, i.e., for hand assist device was placed uneventfully. The splenic flexure was then taken down to facilitate the anastomosis. At this point, the abdomen was then opened as the GelPort was lifted in the sigmoid and distal descending colon, completely visualizing the wound. The iliac vessels were visualized, and at this point I decided to then add the hand-assist GelPort. The lower abdomen in the midline was injected with local anesthesia. A 7 cm incision was made and taken down through the skin and subcutaneous tissue. The peritoneum was opened, and the GelPort was placed into the abdomen. The abdomen was reinsufflated. I was then able to get my left hand into the abdomen and determined that there were significant adhesions on the left side of the sigmoid colon as it turned into the rectosigmoid junction. GelPOINT system The GelPOINT ring retractor was placed (surgery happens) The robot was undocked, and the Alexis system was then used to place the uterus in a bag, which was then brought through the GelPOINT ring retractor. The uterus was grasped and morcellated in a contained system, bringing the bag and everything up through the GelPOINT system as the uterus was removed. The contents of the uterus were then sent for pathology. The GelPOINT ring cap was reattached to this. Insufflation with CO2 showed all pedicles were hemostatic. The cuff appeared secure. The ureters were noted to be peristalsing in their normal location, and the procedure was considered complete. GelPOINT cap was removed. The ring was removed 5

6 GelPOINT Mini with Robot The abdominal cavity was entered; however, it was evident that the patient had significant adhesions of the omentum to the midline and therefore, the Mini GelPOINT was placed in this location. vessels were dissected out and then a 12-mm port had been placed in the Mini GelPOINT and through this, the Endo-GIA 45- mm vascular cartridge was brought in and the vessels were divided. the 12-mm port for the da Vinci camera was closed using the Endo Close device using 0-Vicryl and then the specimen was exteriorized through the stoma site that had been created and the GelPOINT removed. GelPOINT Path system A GelPort was inserted into the anus and secured in place with silk stitches. Final Questions Entering the abdomen laparoscopically for right colectomy was uneventful and pneumoperitoneum was obtained. Once the colon was fully mobilized laparoscopically a 4 cm right lower quadrant incision was made. The abdomen was then entered and a wound protector was then placed. The terminal ileum and cecum were then extracted through this. Once an area of adequate distance approximately 10 cm from the tumor was selected, it was divided with a GIA stapler. The same was done on the proximal and on the terminal ilium. Next, a side-to-side stapled functional end-to-end anastomosis was created between the terminal ilium and the proximal transverse colon and the remaining enterotomy was closed with TA-60 stapler. The tissue was placed back into its anatomic position Which surgical approach is this? 1. Laparoscopic converted to open 2. Laparoscopic 3. Robotic converted to open 4. Open What type of anastomosis is this? 1. Stapled with an EEA (or circular) stapler (end-to-end) 2. Stapled with an EEA (or circular) stapler (side-to-end) 3. Stapled with a GIA stapler (side-to-side) 4. Hand-sutured through the abdomen Thank you 6